MDS Alert

What the manual says about completing Z0400 when someone cannot sign the attestation.

Effective for Oct. 1, the Centers for Medicare & Medicaid Services (CMS) released the latest update of the Resident Assessment Instrument (RAI) manual v1.11. And you’ll find a whole host of significant changes that will greatly affect how you code the MDS — as well as how your residents classify into RUGS for payment purposes.

“While news of the major changes … was included in the prospective payment system (PPS) final rule for rates beginning Oct. 1, the manual fully implements the policy,” wrote Evvie Munley, senior health policy analyst for Washington, DC-based Leading Age, in an Oct. 4 announcement. The manual revisions incorporate clarifications into existing coding and transmission policy, integrate previously published Q&As, and address requested clarifications and scenarios for certain complex areas.

Heed Sections G & M Revisions

For Item G0110 — Activities of Daily Living (ADL) Assistance, the RAI manual extensively revises the “Rule of Three,” the ADL Self-Performance Algorithm, stated the Texas Department of Aging and Disability Services (DADS) in a Sept. 25 analysis of the RAI manual changes. The update also “adds several resident scenarios and rationales for correctly coding those situations.” (See “How The ‘Rule Of 3’ Is Changing — Again” on page 109 for more details on the ADL changes.)

In Section M, the update replaces the MDS Item Set screen shots for several updated items and replaces references to “necrotic tissue” with “eschar,” DADS notes.

How ‘Continence’ Changed in Section H

Section H has only minor changes, but you’ll want to take a look at the revision to the definition of “continence,” noted the University of Missouri Sinclair School of Nursing (UMSSN) in an analysis of the RAI changes posted on its site NursingHomeHelp.org.

New: The MDS now defines “continence” as: “Any void that occurs voluntarily, or as the result of prompted toileting, assisted toileting, or scheduled toileting.”

“Previously, the void could not be considered continent unless it occurred in a commode, bedpan or urinal,” wrote MDS consultant Judy Wilhide Brandt, BA, RN, RAC-MT, in a recent summary and commentary for Leading Age. “Now, a voluntary void into an inappropriate location is still considered an episode of continence.”

Why Section K Updates Look Both Minor & Major

The update renumbers Section K from Item K0700 to K0710 — Percent Intake by Artificial Route, and expands this section to include coding for “While NOT a Resident,” “While a Resident,” and “During the Last 7 Days.”

But the bigger change in this section is now you’ll need to code the total calories a resident receives through an “artificial route,” according to a recent blog posting by the Indianapolis-headquartered law firm Hall, Render, Killian, Health & Lyman. (See “Get Ready To Count Calories In Section K” on page 115 for more details.)

Look for Significant Changes in Section O, Minor Changes in Q

In Section O, the manual revisions add data points where you need to capture the total number of minutes for which a resident received co-treatments, Hall Render said. You’ll need to capture the co-treatment minutes for each type of therapy.

Also, Section O has a new item: O0420 — Distinct Calendar Days of Therapy. For Item O04020, you’ll need to capture the actual number of calendar days in which the resident received therapy services during the seven-day look-back period, DADS said. (See “Code New Item O0420 This Way To Comply With RAI Revisions” on page 116.)

Section Q includes basically one change of any relevance: what Code 9 means in Item Q0100 — Participation in Assessment, the UMSSN said. The manual changes Code 9 to mean “resident has no guardian or legally authorized representative.”

Follow New Signature Rules for Section Z

The manual adds language in Item Z0400 — Signatures of Persons Completing the Assessment that clarifies what to do when someone cannot sign. “If a person who completed a portion of the MDS is not available to sign it (the example given is that the person is no longer employed), then the person signing the attestation should verify those portions of the MDS that may be verified with the medical record and/or interviews as appropriate,” DADS noted.

Double work: The updates also stipulate that “for sections requiring resident interviews, the person signing the attestation should interview the resident to ensure the accuracy of the information and sign on the date this verification occurred,” DADS stated.

Link: To view the updated RAI manual, along with the replacement pages and change tables, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Scroll to the bottom of the Web page to click on the links in the Downloads section.